Pietro Impellizzeri

Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula repair: review of the literature and meta-analysis.

INTRODUCTION The thoracoscopic approach to esophageal atresia (EA) with tracheoesophageal fistula (TOF) represents a challenging procedure whose real benefits remains unclear. Our purpose is to identify, through a meta-analysis, clinical evidence of the reliability of the thoracoscopic repair (TR) for EA/TOF compared with the open repair. MATERIALS AND METHODS Defined PubMed search, with analysis of intraoperative and postoperative complications after open or thoracoscopic primary anastomosis for EA/TOF. RESULTS Five articles met the criteria of meta-analysis, being comparative studies between TR and conventional open repair (COR), although they were retrospective. One article was excluded because it was available only in Japanese. We observed a slight prevalence, statistically insignificant, of the intraoperative and postoperative complication rate for TR: odds ratio (OR) 1.29. Excluding the conversion rate, the meta-analysis between the complication rate for TR and COR did not show a significant difference (OR 0.64). Anastomosiss leaks and strictures considered together did not show a significant difference between the two techniques, p = not significant and OR of 0.56. Similar results were observed analyzing the single outcome of leaks and strictures; the meta-analysis did not show any significant differences with an OR, respectively, of 1.05 and 0.43. CONCLUSIONS The effectiveness of the endoscopic technique for EA/TOF repair is indicated with outcomes not different from open surgery. A randomized controlled trial is needed in this field to indicate which procedure is superior, open or TR.

Late hormonal function after testicular torsion

INTRODUCTION Testicular torsion may be an important cause of male infertility. We aimed to investigate the late hormonal function in patients with testicular ischemia/reperfusion injury of the testis after orchidectomy or detorsion. METHODS Twenty patients (mean age, 13.6 years) were prospectively evaluated at a mean of 5 years after testicular torsion. The serum follicle-stimulating hormone, luteinizing hormone (before and after gonadotropin-releasing hormone stimulation), testosterone, and inhibin B were measured. Fifteen age-matched adolescents without evidence of endocrine disease were used as controls for inhibin B values. Data are quoted as mean +/- SEM. RESULTS Twelve patients were treated with detorsion and orchidopexy, and 8 underwent orchidectomy. Serum follicle-stimulating hormone, luteinizing hormone, and testosterone were all within the reference range. Inhibin B levels were significantly reduced in the 2 groups compared with the controls (34.5 +/- 5.2 vs 63.9 +/- 12.8 pg/mL, P = .02), but were not significantly different between the orchidectomy group and the group that underwent detorsion (41.3 +/- 9.7 vs 30.4 +/- 5.9 pg/mL, P = .41). CONCLUSION Hormonal testicular function can be compromised after testicular torsion, although the type of surgery (orchidectomy or orchidopexy) does not seem to change the effect of this ischemia/reperfusion injury.

PLEUROPULMONARY BLASTOMA: LONG-TERM SURVIVAL AND LITERATURE REVIEW

BACKGROUND AND PROCEDURE Pleuropulmonary blastoma (PPB) identifies different types of pulmonary tumors in the pediatric age. It is extremely uncommon and is known to have a very poor prognosis, with only few cases surviving after 10 years follow-up. Our experience with such a patient and long-term follow-up (12 years) is therefore of interest. She was a 2-year-old girl admitted with a history of respiratory distress and underwent a left thoracotomy. The tumor was removed and after 1 month a polychemotherapy course was started using dactinomycin and vincristine for 6 months. The patient remains disease-free 12 years after the operation. CONCLUSIONS The biologic behavior of the tumor is considered unpredictable, and for this reason much effort has been expended in trying to identify prognostic factors. The preoperative size of the mass (size <5 cm) in our patient, its complete excision, and the histologic aspects might be helpful in identifying favorable prognostic factors.

Ultrastructural and immunohistochemical study of basal lamina of the testis in adolescent varicocele

OBJECTIVE To evaluate a possible involvement of the extracellular matrix (ECM) in the testes of adolescents with varicocele. DESIGN Cross-sectional study. SETTING University-based medical center. PATIENT(S) Twenty-four adolescents aged between 13 and 18 years underwent surgical treatment for repair of left idiopathic varicocele. INTERVENTION A testis biopsy was performed at time of surgery. MAIN OUTCOME MEASURE(S) Transmission electron microscopy study of basal lamina and immunofluorescence studies of collagen type IV and laminin, two major components of basal lamina. RESULT(S) Transmission electron microscopy observations showed an uneven profile of the basal lamina with a variable thickness. Immunofluorescence studies showed an irregular immunofluorescent line that appeared interrupted in some observations. Collagen type IV showed some areas of strong immunostaining with other areas with reduced immunoreactivity. CONCLUSION(S) Our ultrastructural and immunohistochemical observations highlight focal damage at the level of peritubular basal lamina, but this damage is not as severe as that described in adult varicocele. Initial involvement of basal lamina could represent one of the mechanisms responsible for varicocele-induced histologic alterations of the testes.

Sclerotherapy for cervical cystic lymphatic malformations in children. Our experience with computed tomography-guided 98% sterile ethanol insertion and a review of the literature

PURPOSE The treatment of cystic lymphatic malformations of the neck and mediastinum is controversial. Surgical management may be limited by the invasiveness of the procedure, the complex anatomy of this region, and the high recurrence rate. An alternative therapeutic method is sclerotherapy. We report our experience in the treatment of cystic lymphatic malformations of the neck by computed tomography (CT)-guided instillation of 98% sterile ethanol in children. METHODS Eight children with clinical suspicion of cervical cystic lymphatic malformation were assessed by ultrasonography (US) and magnetic resonance imaging (MRI) to define the location, size, and number of cystic cavities. The CT-guided instillation of 98% sterile ethanol was performed. Cystic fluid was analyzed by fine-needle aspiration cytology. Clinical and US or MRI follow-up was performed after 1 and 3 months and at 1 and 2 years. RESULTS The results were excellent with complete disappearance of the lesion in 7 (87.5%) of 8 patients. One patient (12.5%) with satisfactory results required a second alcohol injection with an excellent outcome. No allergic reactions or complications were observed. CONCLUSIONS The CT-guided 98% sterile ethanol sclerotherapy is a good alternative to surgical therapy. This procedure seems accurate, minimally invasive, safe, low cost, and reliable without untoward complications. Moreover, it does not exclude later surgical treatment.

Accessory spleen torsion: rare cause of acute abdomen in children and review of literature

Torsion of an accessory spleen is an extremely rare condition. We describe an unusual case of acute abdomen caused by torsion of an accessory spleen in a 12-year-old boy. The patient underwent a laparotomy with splenectomy; the course was favorable. We discuss the clinical findings and values of preoperative instrumental diagnosis. The literature is also reviewed. This is the 11th case reported in the English literature. Torsion of an accessory spleen should be considered in the differential diagnosis of acute abdomen or subacute abdominal pain.

Oxidative Stress-Mediated Damage in Newborns with Necrotizing Enterocolitis: A Possible Role of Melatonin.

BACKGROUND Necrotizing enterocolitis is a gastrointestinal surgical emergency in premature neonates. Free radicals have been linked to the development of the disease in infants. Ischemia, hypoxia-reperfusion, infection, and inflammation produce elevated levels of reactive oxygen species, impairing the redox balance and shifting cells into a state of oxidative stress. Melatonin, an effective direct free-radical scavenger and indirect antioxidant agent, exerts pleiotropic action on the human body. Several studies have tested the efficacy of melatonin in counteracting oxidative injury in diseases of newborns. Melatonin has been widely used in newborns including cases of asphyxia, respiratory distress syndrome, and sepsis, and no significant toxicity or treatment-related side effects with long-term melatonin therapy have been reported. CONCLUSION Therefore, melatonin, besides standard therapies, could be considered as a potentially safe approach to prevent and treat necrotizing enterocolitis in premature infants. This review summarizes what is known about the role of oxidative stress, and potentially beneficial effects of antioxidants, such as melatonin, in necrotizing enterocolitis.

Varicocele and sport in the adolescent age. Preliminary report on the effects of physical training.

The effect of physical training on the natural history of varicocele has received little attention. The aim of the present pilot study was to evaluate the prevalence of idiopathic varicocele in young athletes, in the attempt to find a correlation between the training workload and the clinical grade of varicocele. We evaluated 150 adolescents with an age of 10–16 yr (median age: 13 yr). All these subjects were athletes practicing different sport at agonistic level. One hundred and fifty non-athlete adolescents of matched age (median: 13.5 yr) were used as controls. All underwent physical examination, and if a varicocele was suspected, the diagnosis was confirmed or excluded by echo-color-Doppler examination. The young athletes were stratified into two groups according to the different time spent for training: Group 1–6 h training per week; Group 2–7 to 12 h per week. Statistical analysis was performed. A p<0.05 was considered significant. The physical examination revealed a clinical varicocele on the left side in 20 athletes. A significant positive correlation was observed between the Group 2 and the highest grade of varicocele (r2=0.9918, p=0.0041). In the adolescent group used as control we observed a varicocele in 16 cases. A positive correlation was observed between the number of athletes with varicocele and the highest grade of varicocele (r2=0.96, p=0.02). Sport training does not modify the prevalence of varicocele compared to the general population, but physical activity has to be considered as an aggravating factor in the natural history of varicocele. In countries where sport eligibility is necessary for agonistic sport practice, varicocele should be then considered as a conditioning factor.

Immunofluorescence distribution of actin-associated proteins in human seminiferous tubules of adolescent testes, normal and pathologic.

The aim of our study on human seminiferous tubules of adolescent testes was to study the localization of two actin-associated proteins of the adherens junctions, such as vinculin and talin, and to verify if there were modifications in their pattern in varicocele, a frequent disease of the testis in adolescent age. The study group consisted of 8 biopsies from normal testes (i.e., adolescents operated on for hydrocele or inguinal hernia) and 20 biopsies from pathological testes (i.e., adolescents operated on for idiophatic left varicocele). Biopsies were evaluated by indirect immunofluorescence using anti-human vinculin and anti-human talin antibodies. Observation was recorded with a Leica TCS 4D upright confocal microscope. In the normal testes, there was a strong positive immunoreactivity for vinculin, which was localized in the interstitial cells of Leydig, and both basal pole and lateral cell surface of Sertoli cells; the pattern of talin immunoreactivity was the same except that the lateral cell surface of Sertoli cells was not stained. In the varicocele group the pattern was different. Vinculin immunoreactivity showed small patches of fluorescence only in the cytoplasm of Sertoli cells while talin immunoreactivity showed a scanty distribution at the basal surface of Sertoli cells. These results confirm that, similarly to other tissues, vinculin is expressed at cell-cell and cell-matrix adherens junctions, while talin is present at cell-matrix adherens junctions in human seminiferous tubules of normal adolescents. Varicocele alters the patterns of these two proteins both quantitatively and qualitatively.

A possible role of the plasmalemmal cytoskeleton, nitric oxide synthase, and innervation in infantile hypertrophic pyloric stenosis. A confocal laser scanning microscopic study.

Abstract In reference to a possible neuropathy in the pathogenesis of infantile hypertrophic pyloric stenosis (IHPS), previous studies have described alterations in peptidergic transmission while others have recently attributed an important role to nitrinergic activity. Little attention has been given to the organization of the extracellular matrix (ECM) and the constituent cytoskeleton and subsarcolemma of the pyloric smooth-muscle cell. To study a possible relationship between neuronal and muscular elements in IHPS, 9 biopsies from patients with IHPS and 5 biopsies of normal pylorus were examined using immunohistochemical techniques with regard to the distribution of nerve cells and fibers (bNOS and PGP 9.5) and the ECM (laminin) and cytoskeleton (talin, vinculin, dystrophin, α-smooth iso-actin, desmin) components of the pyloric muscle. Our results showed anti-protein gene product 9.5 and b-nitric oxide synthase immunoreaction respectively reduced or absent in nerve fibers with a positive reaction inside the ganglion cells. An uneven distribution of the ECM component laminin was evident, together with a negative immunoreaction to talin and dystrophin. The imunolocalization of vinculin, α-smooth iso-actin, and desmin was similar to the controls. Our findings suggest that there is a close relationship between the nerve and muscle elements in the pathophysiology of IHPS and that non-alteration of some elements of cytoskeleton organization can play an important role in regaining pyloric function after pyloromyotomy.